Case 18: Acute change in personality
Friday, May 6th, 2011Author: Dr Amar Mashru
A 33 year old, high-flying, female banker of Vietnamese origin, with no known psychiatric or significant medical history, was brought to A&E by ambulance after her family became very concerned about a marked and acute change in her personality. Over the preceding 24hrs she had adopted a variably mute state and was acting very strangely in her family home; appearing frightened and paranoid and running out into the street in her pyjamas.
She was reviewed by the psychiatry SHO who elicited a history of several weeks of third person auditory hallucinations of a derogatory nature on a background of low mood and hopelessness for a number of years. She was guarded, suspicious and appeared to be responding to visual and auditory hallucinations. There was no history of substance misuse, previous similar episodes or a family history of psychiatric disease.
The diligent psychiatry SHO also noted a macular rash over the patient’s face which her family noted had appeared over the last week. He requested some basic medical investigations, the immediately available of which revealed HR 66, T 37.6°C, BP 157/87 and a normal full blood count.
Her transfer to a psychiatric ward was refused pending further medical investigation.
1. What are the possible medical causes for this presentation?
Click to see the answerThis patient presents with features of an acute psychotic episode. As well as psychiatric illness and the effects of exogenous substances, psychosis can also be the result of a number of medical conditions which would warrant consideration in a case such as this.
They include:
- HIV and AIDS
- malaria
- syphilis
- Alzheimer’s disease
- Parkinson’s disease
- hypoglycaemia
- lupus
- Lyme disease
- multiple sclerosis
- brain tumour
In this young lady’s case subsequent investigation lead to a diagnosis of SLE induced psychosis, with the only potential giveaway on presentation being the typical “butterfly” rash which had developed a few days before admission.
2. How common is this presentation?
Click to see the answerThe huge range of neurological and psychiatric disorders that can manifest as a result of Systemic Lupus Erythematosus are broadly termed neuropsychiatric lupus. The American College of Rheumatology have attempted to classify this heterogeneous subset, including one of psychiatric disorder, which umbrellas manifestations of anxiety, mood disorder (depression) and psychosis.
Due to a lack of standardised criteria and methods, the mechanisms, definitions, treatments and outcomes of neuropsychiatric lupus however remain poorly understood. What is known is that psychiatric disease as a result of SLE is rare occurring in about 2.5% of those diagnosed with lupus, and there are no clear predisposing factors. In the majority of cases the psychiatric pathology presents in conjunction with the first presentation of SLE, and it is rarely a late complication of the disease. Furthermore, it is often within the context of florid activity of the disease (as evidence by concomitant rises in ESR), and is associated more often with cutaneous or haematological manifestations of lupus rather than, say, renal disease. Haematologically, it has been suggested that those with SLE psychosis are unique in their absence of aPL autoantibodies, but this should be treated with some scepticism.
3. What management plan should be initiated and what outcome would you expect?
Click to see the answerThis is complex presentation requiring the coordinated input of a variety of senior specialists. There is no standardised treatment, however invariably disease is controlled with a combination of antipsychotic, corticosteroid and immunosuppressive agents. Fortunately, evidence seems to suggest that response is very good with up to 70% having complete remission at 20 years.
In this particular case the young lady required a lengthy stay under the care of Rheumatology and Renal physicians, with intensive outpatient follow-up, as well as a prolonged period of psychiatric inpatient admission with slow, but excellent recovery of her psychotic symptoms mirroring successful remission of her lupus.
4. What psychiatric medications could be used for the treatment of this condition?
Click to see the answerPsychosis associated with SLE tends to follow the course of the primary disease and management of this is therefore the priority. Patients will often require additional antipsychotic medication however and it is worth considering a few of the drugs available.
Antipsychotics are colloquially divided into typical (older) and atypical (newer) types. This is a misnomer however; the only true atypical antipsychotic medication is Clozapine. All other antipsychotics exert their action through dopamine antagonism to some extent but the second generation (atypical) drugs seem to have a more preferable side effect profile, due to their reduced dopamine antagonism and involvement with other neurotransmitters, e.g. serotonin. The atypical antipsychotics include:
- Amisulpride
- Aripiprazole
- Olanzapine
- Quetiapine
- Risperidone
- Clozapine
The older (typical) antipsychotics are associated with increased prevalence of extrapyramidal side effects and include:
- Chlorpromazine
- Haloperidol
- Pimozide
- Sulperide
It is worth mentioning Clozapine, the only true atypical agent. It has little involvement with the dopamine system and is an excellent antipsychotic medication. Unfortunately it is associated with pancytopenia, liver dysfunction, tachycardia and other arrhythmias. For this reason all patients on Clozapine are subject to regular blood tests, ECG and medical review. If you see any of these patients, they will probably have a lot of recent blood tests and ECGs in their records.
It is always important to be aware of antipsychotic medications in the Emergency setting, being mindful of the fact that many patients refer to them under their various trade names and that, if in a depot form, they may not appear on their regular prescription or Dossete box. They all have a significant side effect profile, interact with other medications and can be fatal in overdose.